A 10-Year Investigation of the Causes and Rates of Deaths Due to Four Different Surgical Weight Loss Methods in Tehran

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A 10-year Investigation of the Causes and Rates of Deaths due to Four Different Surgical Weight Loss Methods in Tehran

Mehdi Mesri1, Masoud Ghadipasha2*, Mehdi Forouzesh2, Aram Samira2, Alimohammad Alimohammadi2, Seyed Hassan Saadat3, Seyed Morteza Hosseini1, Mohammad Chehrazi4

1Medicine, Quran and Hadith Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran 2Research Center of Tehran Forensic Medicine Organization, Forensic Medicine, Legal Medicine Organization Research Center, Tehran, Iran 3Psychology-behavioral Sciences Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran 4Department of Epidemiology and Reproductive Health, Reproductive Epidemiology Research Center, Royan Institute for Reproductive Biomedicine, ACECR, Tehran, Iran

ABSTRACT Background: Weight loss is associated with reductions in comorbidities. Weight loss surgery improved weight loss outcomes more than non-surgical interventions but it is associated with adverse effects. Two objectives for this study were: first to compare death rates between two different purposes of these surgeries (therapeutic vs. aesthetic); and second to determine autopsy causes of deaths among them. Methods: Authors studied all deaths due to surgical weight loss methods (gastric bypass; sleeve gastrectomy; abdominal liposuction; gastric balloon) referred to the forensic medicine dissection hall in Tehran city from 2008 to 2017 within a retrospective cross-sectional study. We divided them into two different groups according to purpose of surgery (Group A (therapeutic) vs. Group B (aesthetic). Results: Authors studied 44 cases, including 12 men and 32 women. Most victims in both groups were in the age range of 31–40 years. Gastric bypass was the most frequent surgical method in Group A, on the other hand, in Group B, it was abdominal liposuction. The most common cause of death was peritonitis in Group A; in Group B, it was pulmonary thromboembolism. The total number of deaths increased during study. Conclusions: The findings showed that deaths in females were more common in both groups; this may be because women are more likely to undergo these kinds of surgeries; but it may be because female’s immunity system specificities’ like Interleukins and the same as females immunity system role in their mortality dominancy in burns. Further investigation needs to determine causes of females’ mortality dominances’ in weight loss surgeries.

Key words: Death, Weight loss, Surgical method, Tehran

HOW TO CITE THIS ARTICLE: Mehdi Mesri, Masoud Ghadipasha*, Mehdi Forouzesh, Aram Samira, Alimohammad Alimohammadi, Seyed Hassan Saadat, Seyed Morteza Hosseini, Mohammad Chehrazi, A 10-year investigation of the causes and rates of deaths due to four different surgical weight loss methods in Tehran, J Res Med Dent Sci, 2018, 6(6): 202-207

Corresponding author: Masoud Ghadipasha hypertension and improvement in lipid profiles are less e-mail✉: [email protected] clear. Compared to conventional treatment, surgery is also Received: 19/11/2018 Accepted: 21/12/2018 associated with greater short term improvements in some aspects of health related quality of life, but not others. A systematic review showed that weight loss surgery INTRODUCTION improved weight loss outcomes more than non-surgical Obesity is associated with many health problems and a interventions. Surgery and conventional treatment were higher risk of death. The weight loss is associated with both associated with adverse effects [1]. reductions in comorbidities, such as diabetes, metabolic syndrome and sleep apnea, although the benefits for

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Several studies show that weight loss or bariatric surgery surgical deaths in Tehran dissection hall, we were able to may have a role in treating Obstructive sleep apnea (OSA) obtain all the autopsy files related to any kind of deaths [2]. after weight loss surgical methods. Gastrointestinal surgery has excellent but variable Data collection outcomes on the glycemic control of diabetic patients depending on the type of surgery. The metabolic effect of We designed a questionnaire containing all information bariatric/metabolic surgery on T1DM has elicited required in our study such as gender, age-group, past significant interest because of the already-proven drug history, past medical history, aim of weight loss benefits on T2DM and the potential production of similar surgery (therapeutic vs. aesthetic), type of surgery and results for T1DM, which forms 10% of diabetic load [3]. autopsy cause of death each year. For assess our The most effective therapy to treat obese and related questionnaire validity, we sent it to two social medicine comorbidities is bariatric surgery, in which Roux-en-Y specialists and one epidemiologist and also for assessing gastric bypass (RYGBP) and sleeve gastrectomy (SG) are its reliability we registered each questionnaire autopsy two most popular procedures. SG is one of the most file number. popular procedures (37%) in the world. SG is a The data from the autopsy files belonged to weight loss technically less complex procedure with short learning surgeries’ deaths from all hospitals of Tehran was curve and effective weight loss, but it suffers from two extracted to complete our questionnaire. We had not outstanding disadvantages including high risk of weight mentioned any deceased identity information in our regain and gastro-esophageal reflux disease (GERD). study. We had extracted public data from their autopsy Mini-gastric bypass (MGB), also known as single files such as sex, age-group, autopsy cause of death, past anastomosis gastric bypass or omega gastric bypass is a diseases, past drug history and total numbers each year. newly emerged procedure originated from Rutledge. Due The Code of ethical approval is IR.LMO.REC.1396.37. to safe and simple process as well as effective outcomes, MGB has quickly become one of the most popular procedures in many countries. Despite of popular status, Inclusion and exclusion criteria the extension of MGB is still limited by some concerns The exclusion criteria in our study were insufficient data such as gastric and esophageal bile reflux, marginal ulcer, on characteristics of any weight loss surgical death; poor follow-up, and remnant gastric cancer [4]. Visceral however, there were any autopsy file with insufficient adipose tissue (VAT) is an important risk factor for the data. The total numbers of weight loss surgical deaths metabolic complications associated with obesity. during ten-year study were fifty-one. Among them; Therefore, a reduction in VAT is considered an important autopsy found seven positive toxicology samples, target of obesity therapy [5]. Fat embolism syndrome therefore we excluded these files from our data, because may occur in patients suffering from multiple traumas we wanted to study pure weight loss surgical deaths (long bone fractures) or plastic surgery (liposuction), without effect of any drug, opioid, stimulants or alcohol compromising the circulatory, respiratory and/or central in victims’ blood or tissue samples. Thus, from fifty-one nervous systems [6]. We did not find any official and weight loss surgical autopsy files, forty-four files were definitive statistics about the number and causes of included in our study. deaths related to surgical weight loss methods in Iran. Therefore, we aimed to study all deaths due to four Statistical analysis surgical weight loss methods (abdominal liposuction, sleeve gastrectomy, laparoscopic gastric balloon, and By examining the autopsy files from Tehran forensic gastric bypass surgery) referred to the forensic medicine medicine dissection hall and compared with male and dissection hall in Tehran city from 2008 to 2017, within a female characteristics of deaths during the ten-year retrospective cross-sectional study. study, data were coded and analyzed by SPSS version 24 software. We utilized descriptive statistics, chi-square MATERIALS AND METHODS test and independent sample t-test. Significance level was recorded as p<0.05. Study design RESULTS In this retrospective cross-sectional study, we examined the autopsy reports of all deaths due to four surgical Gender weight loss methods including laparoscopic Roux-en-Y gastric bypass (GB), laparoscopic sleeve gastrectomy During our ten-year study, there were 44 victims, (SG), abdominal liposuction, laparoscopic adjustable including 12 (27/3%) men and 32 (72/7%) women. gastric banding or laparoscopic gastric balloon (referred Incidence of death in female was more than male to the forensic medicine dissection hall in Tehran) during (p<0/001), it may be showed female tendency to 10 years from March 2008 to March 2017. As a rule, all undergo weight loss surgeries more than male tendency, deaths related surgeries in any hospital of Tehran must but There is not statistically difference between gender refer to the dissection hall in order to determine certain and cause of death (p=0/26). cause of death through autopsy; accordingly, when we We divided the victims into two different groups (A and investigated the autopsy files of all post (weight loss) B) according to their aim for undergoing surgical

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methods (therapeutic vs. aesthetic). There were 23 The gender distribution has been shown in Table 1 and (52/3%) deaths in Group A vs. 21 (47/7%) deaths in Figure 1. Group B. Death was more common in Group A (therapeutics) in males while it is quite the opposite in females.

Table 1: Characteristics of deaths due to surgical weight loss methods during ten-year study

Variables Group A (Therapeutics) Group B (aesthetics) Total

Number 23 (52/3%) 21 (47/7%) 44 (100%)

Sex Male 10 (22/7%) 2 (4/5%) 12 (27/3%)

Female 13 (29/5%) 19 (43/2%) 32 (72/7%)

1-20 1 (2/3%) 0 1 (2/3%)

21-30 1 (2/3%) 4 (9/1%) 5 (11/3%)

31-40 12 (27/3%) 8 (18/1%) 20 (45/4%) Age Group (In Years) 41-50 7 (15/9%) 6 (13/6%) 13 (29/5%)

51-60 2 (4/6%) 2 (4/6%) 4 (9/1%)

61-70 0 1 (2/3%) 1 (2/3%)

Gastric Bypass 10 (22/7%) 2 (4/6%) 12 (27/3%)

Sleeve Gastrectomy 4 (9/1%) 3 (6/8%) 7 (15/9%) Surgical Procedure Abdominal Liposuction 4 (9/1%) 16 (36/3%) 20 (45/4%)

Intra gastric Balloon 3 (6/8%) 2 (4/6%) 5 (11/3%)

Septicemia 3 (6/8%) 2 (4/6%) 5 (11/3%)

Peritonitis due to Intestinal Perforation 12 (27/3%) 2 (4/6%) 14 (31/8%)

Bleeding 1 (2/3%) 3 (6/8%) 4 (9/1%)

Lidocaine Toxicity 0 0 0

Autopsy cause of death Intestinal Obstruction 0 0 0

Pulmonary Thromboembolism 3 (6/8%) 9 (20/4%) 12 (27/3%)

MultiOrgan Failure 0 2 (4/6%) 2 (4/6%)

Acute myocardial Infarcation 4 (9/1%) 2 (4/6%) 6 (13/6%)

Hypoxic Ischemic Encephalopathy 0 1 (2/3%) 1 (2/3%)

Past Medical History 2 (4/6%) 0 2 (4/6%)

Past Drug History 2 (4/6%) 0 2 (4/6%)

2008 0 2 (4/6%) 2 (4/6%)

2009 0 1 (2/3%) 1 (2/3%)

2010 1 (2/3%) 2 (4/6%) 3 (6/8%)

2011 2 (4/6%) 1 (2/3%) 3 (6/8%)

2012 1 (2/3%) 2 (4/6%) 3 (6/8%) Year 2013 2 (4/6%) 1 (2/3%) 3 (6/8%)

2014 6 (13/6%) 1 (2/3%) 7 (15/9%)

2015 2 (4/6%) 3 (6/8%) 5 (11/3%)

2016 4 (9/1%) 2 (4/6%) 6 (13/6%)

2017 4 (9/1%) 6 (13/6%) 12 (27/3%)

*There is no statistical difference between gender and cause of death (p=0/26)

**There was no statistical difference between cause of deaths according age-group (p=0.79)

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***Overall there was statistically difference between cause of deaths according to aim of surgery (p=0.04)

Figure 1: Sex among two groups

Age-group Figure 3: Surgical methods among two groups There was one (2/3%) victim between 1–20 years; five (11/4%) victims between 21–30 years; nineteen Causes of death as per autopsy (43/2%) victims between 31–40 years; fourteen According to autopsy reports, the causes of deaths (31/8%) victims between 41–50 years; four (9/1%) included septicemia: five (11/3%); peritonitis due to victims between 51–60 years; and one (2/3%) victim intestinal perforation: fourteen (31/8%); bleeding: four between 61–70 years (mean age ± SD: 35.2 ± 4.1 years). (9/1%); Pulmonary thromboembolism (PTE): twelve Deaths in age-group between 31-40 years were (27/3%); multi-organ failure (MOF): two (4/6%); acute statistically more than other age-groups, but there was myocardial infarction: six (13/6%); and hypoxic ischemic no statistically difference between cause of deaths encephalopathy: one (2/3%). The most common autopsy according age-group (p=0.79). The age-groups details causes of deaths were peritonitis due to intestinal have been shown in Table 1 and Figure 2. perforation 14 (31/8%) and Pulmonary thromboembolism 12 (27/3%), respectively. peritonitis due to intestinal perforation was more common in Group A (therapeutics) [12(27/3%)] vs. Pulmonary thromboembolism in Group B (aesthetics) [9(20/4%)]. Figure 4 show the causes of death through weight loss procedures as per autopsy in each group.

Figure 2: Age-groups among two groups

Past drug history There were forty-two (95/5%) patient without any history of medication and two (4/5%) users of antihypertensive drugs.

Past medical history Figure 4: Cause of death as per autopsy among the two groups

During our ten-year study, there were only two (4/5%) Each year rate of deaths patients with hypertension. The yearly death rates due to weight loss procedures in Type of surgical method Tehran were two (4/6%) in 2008; one (2/3%) in 2009; three (6/8%) in 2010, 2011, 2012 and 2013; seven Among the different types of surgical methods, there (15/9%) in 2014; five (11/3%) in 2015; six (13/6%) in were twelve (27/3%) cases of laparoscopic Roux-en-Y 2016; and finally, 12 (27/3%) in 2017. Table 1 and gastric bypass (GB); seven (15/9%) cases of laparoscopic Figure 5 show the yearly death rates due to weight loss sleeve gastrectomy (SG); twenty (45/4%) cases of procedures in each group. abdominal liposuction; and five (11/3%) cases of intra- gastric balloon (laparoscopic gastric balloon). Overall, there was statistically difference between cause of deaths according to aim of surgery (p=0.04). Figure 3 shows the various surgical procedures used in each group.

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is similar to studies performed in Mexico [12], USA [19]; but it is in contrast with studies conducted in many countries [11].

CONCLUSION In this study, our findings showed more female deaths in both groups, this may be due to the increasing number of women undergoing weight loss surgical procedures. For men, healing was a greater aim than beauty; on the other Figure 5: Each year deaths among the two groups hand, it was quite the opposite for women; but it may be because female’s immunity system specificities’ like DISCUSSION Interleukins and, the same as females immunity system In this retrospective cross-sectional study during 10 role in their mortality dominancy in burns. Further years from 2008 to 2017, the autopsy reports of all investigation needs to determine causes of mortality deaths due to four different weight loss surgical methods dominancy in females in weight loss surgeries. We hope (gastric bypass, sleeve gastrectomy, abdominal that our findings can help surgeons choose the best liposuction, and intra-gastric banding) referred to the surgical methods for their patients and perhaps prevent forensic medicine dissection hall in Tehran city were some of these deaths. studied. We extracted the required data from files for our questionnaire, including gender, age, method of surgery, ACKNOWLEDGEMENTS aim of surgical procedure, past medical history, past drug history, cause of death as per autopsy, and number of The authors acknowledge all file archives and thank the deaths each year. The total numbers of weight loss personnel of the dissection hall in the province of Tehran surgical deaths during ten-year study were fifty-one. for their kind cooperation. Among them; autopsy found seven positive toxicology samples, therefore we excluded these files from our data, CONFLICT OF INTEREST because we wanted to study pure weight loss surgical The authors declared no potential conflicts of interests. deaths without effect of any drug, opioid, stimulants or alcohol in victims’ blood or tissue samples. Thus, from REFERENCES fifty-one weight loss surgical autopsy files, forty-four files were included in our study. According to the aim of 1. Colquitt JL, Pickett K, Loveman E, et al. Surgery surgery, we divided our cases into two groups (Group A: for weight loss in adults. Cochrane Database therapeutic; Group B: aesthetic). The main goal of our Syst Rev 2014; 8:3641. study was to investigate the causes of death in patients 2. Dong Z, Hong BY, Yu AM, et al. Weight loss who underwent different weight loss surgical surgery for obstructive sleep apnea with procedures; we also compared deaths between the four obesity in adults: A systematic review and surgical methods. There was a statistically significant meta-analysis protocol. BMJ Open 2018; difference in the female mortality rate (p<0/05); in fact, 8:20876. Incidence of death in female (73%) had statistically 3. Hussain A. The effect of metabolic surgery on significant difference than male (27%) (p<0.05). Also the type 1 diabetes: Meta-analysis. Arch Endocrinol findings showed the most prevalent age group of victims’ Metab 2018; 62:172-8. was 31–40 years in both groups. 4. Wang FG, Yu ZP, Yan WM, et al. Comparison of The present study showed the most common surgical safety and effectiveness between laparoscopic method in Group A (therapeutics) leading death was mini-gastric bypass and laparoscopic sleeve gastric bypass; and this result is in contrast with studies gastrectomy: A meta-analysis and systematic conducted in New York [7], USA [8], Mexico [9] and review. Medicine (Baltimore) 2017; 96:8924. Finland [10]; also our findings showed that in Group B 5. Fabbrini E, Tamboli RA, Magkos F, et al. Surgical (aesthetics), the most common surgery leading death removal of omental fat does not improve insulin was abdominal liposuction and this result is in contrast sensitivity and cardiovascular risk factors in with studies conducted in many countries [11] but it is obese adults. Gastroenterology 2010; similar to studies performed in Mexico [12], Korea [13]. 139:448-55. Our study showed sleeve gastrectomy had a few death 6. De Lima E, Souza R, Apgaua BT, et al. Severe fat rates, so it is a safe method and this result is similar to embolism in perioperative abdominal studies performed in New York [7], USA [8], Finland [10], liposuction and fat grafting. Braz J Anesthesiol Poland [14], USA [15] and New York [16]. 2016; 66:324-8. 7. Shoar S, Saber AA. Long-term and midterm In this study, the most common autopsy causes of death outcomes of laparoscopic sleeve gastrectomy were peritonitis due to intestinal perforation and this versus Roux-en-Y gastric bypass: A systematic finding is similar to studies performed in Czech Republic review and meta-analysis of comparative [17], Italy [18]; and second cause of deaths was studies. Surg Obes Relat Dis 2017; 13:170-80. pulmonary thromboembolism, respectively; this finding

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